Multicenter randomized phase II trial of prophylactic right‐half dissection of superior mesenteric artery nerve plexus in pancreatoduodenectomy for pancreatic head cancer

Yamada, Suguru; Satoi, Sohei; Takami, Hideki; Yamamoto, Tomohisa; Yoshioka, Isaku; Sonohara, Fuminori; Yamaki, So; Shibuya, Kazuto; Hayashi, Masamichi; Hashimoto, Daisuke; Ando, Masahiko; Murotani, Kenta; Sekimoto, Mitsugu; Kodera, Yasuhiro; Fujii, Tsutomu

doi:10.1002/ags3.12399

Cited by 13 publications

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“…These articles are not randomized controlled trials and contain small numbers of patients, rendering the level of the evidence low. A newer publication on the subject [ 5 ] compares two groups of 37 patients operated for pancreatic cancer in a randomized setting where the intervention was either right half dissection of the SMAP or SMAP preservation. The results seem to imply that diarrhea was more often present in the right half dissection of the SMAP (70.3%) when compared to preservation (48.6%), but still not significant.…”

Section: Discussionmentioning

confidence: 99%

Reconstructing topography and extent of injury to the superior mesenteric artery plexus in right colectomy with extended D3 mesenterectomy: a composite multimodal 3-dimensional analysis

et al. 2022

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Background Superior mesenteric artery plexus (SMAP) injury is reported to cause postoperative intractable diarrhea after pancreatic/colonic surgery with extended lymphadenectomy. This study aims to describe the SMAP microanatomy and extent of injury after right colectomy with extended D3 mesenterectomy for cancer. Methods Three groups (I) anatomical dissection, (II) postmortem histology, and (III) surgical specimen histology were included. Nerve count and area were compared between groups II and III and paravascular sheath thickness between groups I and II. 3D models were generated through 3D histology, nanoCT scanning, and finally through 3D printing. Results A total of 21 specimens were included as follows: Group (I): 5 (3 females, 80–93 years), the SMAP is a complex mesh surrounding the superior mesenteric artery (SMA), branching out, following peripheral arteries and intertwining between them, (II): 7 (5 females, 71–86 years), nerve count: 53 ± 12.42 (38–68), and area: 1.84 ± 0.50 mm2 (1.16–2.29), and (III): 9 (5 females, 55–69 years), nerve count: 31.6 ± 6.74 (range 23–43), and area: 0.889 ± 0.45 mm2 (range 0.479–1.668). SMAP transection injury is 59% of nerve count and 48% of nerve area at middle colic artery origin level. The median values of paravascular sheath thickness decreased caudally from 2.05 to 1.04 mm (anatomical dissection) and from 2.65 to 1.17 mm (postmortem histology). 3D histology models present nerve fibers exclusively within the paravascular sheath, and lymph nodes were observed only outside. NanoCT-derived models reveal oblique nerve fiber trajectories with inclinations between 35° and 55°. Two 3D-printed models of the SMAP were also achieved in a 1:2 scale. Conclusion SMAP surrounds the SMA and branches within the paravascular sheath, while bowel lymph nodes and vessels lie outside. Extent of SMAP injury on histological slides (transection only) was 48% nerve area and 59% nerve count. The 35°–55° inclination range of SMAP nerves possibly imply an even larger injury when plexus excision is performed (lymphadenectomy). Reasons for later improvement of bowel function in these patients can lie in the interarterial nerve fibers between SMA branches.

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Section: Discussionmentioning

confidence: 99%

Reconstructing topography and extent of injury to the superior mesenteric artery plexus in right colectomy with extended D3 mesenterectomy: a composite multimodal 3-dimensional analysis

et al. 2022

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“…There were some preliminary evidences that proved the superior survival outcomes of SMA LN circumferential dissection and not increased the rate of postoperative complications especially postoperative diarrhea [ 21 ]. And in another aspect, the concept of right-half dissection of the SMA nerve plexus along with SMA LNs circumferential dissection, in order to accomplish R0 resection with the potential for nerve plexus invasion, showed no significant difference in oncological outcome, as well as significantly increased the rate of postoperative diarrhea requiring opioids according to recent studies and trials [ 26 , 27 ].…”

Section: Discussionmentioning

confidence: 99%

Total laparoscopic pancreaticoduodenectomy with left posterior superior mesenteric artery first-approach and plexus-preserving circumferential lymphadenectomy: step-by-step technique with a surgical case report (with video)

et al. 2022

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Introduction Total laparoscopic pancreaticoduodenectomy (tLPD) for cancer of the Vater remains a challenging procedure. Recently, several meta-analyses showed the superior aspects of “superior mesenteric artery (SMA)-first approach,” “systematic mesopancreas dissection,” and “circumferential lymphadenectomy around SMA” in increasing R0 resection rate and reducing postoperative complications including pancreatic fistula and bleeding as well as improving overall survival particularly. Case presentation Our patient is a 70-year-old female with a no special medical history, recruited because of jaundice. She was referred for pancreaticoduodenectomy because of a 10-mm-sized mass in distal bile duct referred to as Vater’s tumor. We used 5 trocars, and the patient was placed in a Trendelenburg position. The transverse colon was lifted, the first loop of the jejunum was pulled to the left, and lymph node groups 14th and 15th were removed en bloc and then exposed the SMA from the anterior to the left posterior side from the caudal side to the origin. The first jejunal vessels and the posterior inferior pancreaticoduodenal artery were ligated as well as the extensive mobility of the duodenum and head of the pancreas from the left side. The systematic mesopancreas dissection from the right site of the SMA will be easily and conveniently done afterwards. Histopathological examination of ypT2N1 indicated that 1 of the 22 lymph nodes was positive, which was 1 of 7 LN no. 14. Pathological results showed a Vater adenocarcinoma with all margins being negative. Conclusions This technique was safe and effective to perform precise level 2 mesopancreas dissection and complete lymphadenectomy around SMA without dissection of pl-SMA in laparoscopic field.

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“…There were some preliminary evidences proved the superior survival outcomes of SMA LNs circumferential dissection, and not increased the rate of postoperative complications especially postoperative diarrhea [21]. And in another aspect, the concept of right-half dissection of the SMA nerve plexus along with SMA LNs circumferential dissection, in order to accomplish R0 resection with the potential for nerve plexus invasion, showed no signi cant difference in oncological outcome, as well as signi cantly increased the rate of postoperative diarrhea requiring opioids according to recent studies and trials [26,27].…”

Section: Discussionmentioning

confidence: 99%

Total Laparoscopic Pancreaticoduodenectomy with Left Posterior Superior Mesenteric Artery First-Approach and Plexus-Preserving Circumferential Lymphadenectomy: A Surgical Case Report (With Video)

Nguyen

Luong

et al. 2022

Preprint

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Introduction: Total laparoscopic pancreaticoduodenectomy (tLPD) for cancer of Vater remains a challenging procedure. Recently, several meta-analyses showed the superior aspects of “Superior Mesenteric Artery (SMA)-first approach”, “Systematic mesopanreas dissection” and “Circumferential lymphadenectomy around SMA” in increasing R0-resection rate and reducing postoperative complications including pancreatic fistula and bleeding as well as improving overall survival particularly. Case presentation: Our patient is a 70-year-old female with a no special medical history, recruited because of jaundice. She was referred for pancreaticoduodenectomy because of a 10mm-sized mass in distal bile duct referred to Vater’s tumor. We use 5 trocars and the patient placed in a Trendelenburg position. The transverse colon was lifted, the first loop of the jejunum was pulled to the left, the lymph nodes groups 14th and 15th were removed en bloc and then exposed the SMA from the anterior to the left posterior side from the caudal side to the origin. The first jejunal vessels and the posterior inferior pancreaticoduodenal artery were ligated and extensive mobility of the duodenum and head of the pancreas from the left side. The systematic mesopancreas dissection from the right site of the SMA will be easily and conveniently done afterwards. Histopathological examination of ypT2N1 indicated that 1 of the 22 lymph nodes was positive, that was 1 of 7 LNs No. 14. Pathological results showed a Vater adenocarcinoma with all margins being negative. Conclusions This technique was safe and effective to perform precise level-2 mesopancreas dissection and complete lymphadenectomy around SMA without dissection of pl-SMA in laparoscopic field.

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Multicenter randomized phase II trial of prophylactic right‐half dissection of superior mesenteric artery nerve plexus in pancreatoduodenectomy for pancreatic head cancer

Abstract: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Cited by 13 publications

References 19 publications

Reconstructing topography and extent of injury to the superior mesenteric artery plexus in right colectomy with extended D3 mesenterectomy: a composite multimodal 3-dimensional analysis

Reconstructing topography and extent of injury to the superior mesenteric artery plexus in right colectomy with extended D3 mesenterectomy: a composite multimodal 3-dimensional analysis

Total laparoscopic pancreaticoduodenectomy with left posterior superior mesenteric artery first-approach and plexus-preserving circumferential lymphadenectomy: step-by-step technique with a surgical case report (with video)

Total Laparoscopic Pancreaticoduodenectomy with Left Posterior Superior Mesenteric Artery First-Approach and Plexus-Preserving Circumferential Lymphadenectomy: A Surgical Case Report (With Video)

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